Healthcare Provider Details

I. General information

NPI: 1316801087
Provider Name (Legal Business Name): RYAN SHELTERED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 VALHALLA DR NE
POPLAR GROVE IL
61065-9286
US

IV. Provider business mailing address

129 VALHALLA DR NE
POPLAR GROVE IL
61065-9286
US

V. Phone/Fax

Practice location:
  • Phone: 331-230-1154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: FATUMA KIWALA
Title or Position: OWNER
Credential:
Phone: 331-230-1154